The Examination of the Profile of Leadership and Management in Healthcare Institutions in Kosovo

Introduction

I.I Demographic Characteristics and Living Statistics of the Population

The Republic of Kosovo covers an area of 10,908 km2 and has a total population of 1,804,944. It is located in the south-eastern part, bordering south-west with Albania, north-west with Montenegro, north-east with Serbia and south with Macedonia. Population density is 162.41 inhabitants per km2. It has a total of 38 municipalities. Based on the general population number, 28% are under the age of 15 and half of the population are younger than 28.2 years old. The average age of the Republic of Kosovo population estimated in 2011 is 30.2 years old (Kosovo Statistics Agency, 2016). The average life expectancy for men in Kosovo for 2011 is estimated to be 76.6 years, for women 79.4 years (Kosovo Agency of Statistics, 2016). The health sector in the Republic of Kosovo is financed by income tax, co-payments and taxes, while private pocket payments account for 40% of expenditures for health services (Ministry of Health, 2016).

I.II. History of Health Development

The health care system in Kosovo has undergone a transition since the end of the war and has been one of the country's many challenges since 1999. With the help of European countries mainly UNMIK, the Kosovo Health System has begun to taking care of health care management and management, raising the potential of services, hiring healthcare staff and enhancing the renovation of various facilities for providing health services to all citizens regardless of our country. Along with these aids, various donations were provided, including various tools, medicines and technologies that helped improve the quality of health care services (Ministry of Health, 2009). In setting up the quality of health services, in the post-war period of the public sector, the formation of the provisional structures of self-government and division of responsibilities was greatest, and was then transformed into UNMIK Regulation no. 2002/5, which delegates UNMIK's full powers to the country's leading structures. From this period, Kosovo takes over the governance of health institutions. The key document defining the strategic direction and the medium-term approach of the Kosovo Health System is the Health Sector Strategy (SSSH), a document in which are written priorities that need to be achieved in the field of health (Ministry of Health, 2016). Part of the implementation of the Health Sector Strategy 2017-2021 is the Action Plan (PV), which presents the activities to be carried out during the period 2017 - 2019, in particular the PV reflects the strategic directions for healthcare institutions for SSS realization, which offers in detail how to achieve the objectives that are part of HSS. For MOH Action Plan is a measuring instrument for monitoring the applicability of SSSH, as well as an information tool for achieving strategic objectives (Ministry of Health, 2016). The Action Plan is based on the principles and commitment set out in the Tallinn Card Health and Safety System approved by the World Health Organization and the member states of the European region in June 2008 (Action Plan, 2010).

I.Ill Organizational Structure and Health Care Levels

Health care institutions in Kosovo are the same as in the public, private and public-private sectors Institutions by which public health services are provided are classified in three levels of care provision:

• Primary level;

• Secondary level;

• Tertiary level (Ministry of Health, 2009)

The primary level includes the starting point of providing health care, which includes preventive measures through the implementation of the concept of family medicine. The municipalities have the responsibility for primary public health care and for evaluating the health status of citizens in their territory. Within this level, the Main Family Medicine Centers (MFMC), Family Medicine Centers, and Family Medicine Points operate. Emergency Centers (Law No. 04 / L-125, 2012) also exist in countries with over 150,000 inhabitants. Secondary level includes services provided through regional hospitals. They provide stationary treatment (with patient extension) as well as specialized services that include oral care services. Within these services, the Mental Health Professional Service, through the institutions of Mental Health Centers (MCIs), Communities Integration Houses (SHIB), and the Center for Integration and Rehabilitation of Chronic Psychiatric Sickness in Shtime (Ministry of Health, 2012). The tertiary level includes the specialist services provided in public health institutions, the basic lecture at the Faculty of Medicine for students as well as postgraduate studies and scientific research work (Health Law, 2012). Health institutions that are part of KPSHK are autonomous units that organize and manage their regular administrative and professional duties in the function of fulfilling their duties and responsibilities, in addition to the duties and responsibilities that under the Law on Health and this Statute are assigned to HUCSK (Statute of HUCSK, 2013). According to the Statute of HUCSK, HUCSK is organized on the basis of a functional network model that integrates administrative and financial functions with professional and scientific functions in the public health sector, through close cooperation between health institutions - organizational unit of HSCUKK and related services professional (Statute of HUCSK, 2013).

The operational organization of HSUCK is composed of the Steering Board (BD), which is the highest decision-making body of HUCSK. The Steering Board consists of seven (7) members: one (1) representatives from the University Clinical Center of Kosovo (UCCK), one (1) representative from the University Clinical Center of Kosovo, one (1) representative from the National Institute of Public Health Institute, one (1) representative from General Hospitals, based on the rotation and fulfillment of quality health service indicators, one (1) representative from the Primary Health Care Services, based on the proposal of the Association of Municipalities of the Republic of Kosovo, one (1) representative of the Ministry of Health and one (1) Financial Director - experts of economics or health management with high professional and scientific qualifications selected on the basis of a public competition (Statute of HUCSK, 2013).

I.V Health Profiles in Kosovo

Our country still does not have full information on all health profiles that are practicing their profession in Kosovo. According to the Ministry of Health, this is due to the lack of adequate functioning of the Health Information System (HIS) (Ministry of Health, 2009). Health profiles assessed by the Ministry of Health are the worst in Southeast Europe. Based on the results of the Kosovo Information System availability of health profiles is very low compared to other countries where in Kosovo there are 0.94% doctors, 1.61% nurses and 0.06% dentists (Ministry of Health, 2009). Lack of standards for services or protocols increasingly makes it difficult to achieve quality and work management. Managerial jobs are managed through some past technical assistance that is not inconsistent with any regulation or legal framework and can not be used systematically throughout the country.

Based on the Health Law, no. 04 / L-125, the existing profiles that provide health services in public, private and public-private health institutions are: Doctor of Medicine, Doctor of Dentistry (specialist, sub-specialist), Graduate Pharmacist - Master of Pharmacy (specialist, -specialist), Psychologist (specialist, sub-specialist), Nurses, Physiotherapist. Senior Medical Worker, Graduated speech therapist, Graduated Audiologist, Graduate Phonemic and Other Qualified Medical and Senior Professionals, defined in the Ministry's official register (Law on Health, 2012).

The number of staff employed in Primary Health Care is 5,453 of which 4,579 are health workers and 842 non-health workers, out of health profiles, 1,326 doctors, out of which 476 are family medicine specialists and 3,050 are nurses, of which 2,118 are trained family nurses.

According to WHO (2007), health profiles should be properly described and formalized, they should contain:

• clarity about their roles and degree of authority at all levels of the health system;

• clarity about the competences that must be at each level of the health system;

• job descriptions based on the two upper criteria.

In the Health Sector Strategy 2017-2021, the Ministry of Health (2016) aims to improve governance and management of the healthcare system by strengthening and enhancing managerial capacities, including issues related to strategic management and enhancement of professionalism, as a prerequisite requires the comprehensive functioning of the integrated health information system. The Ministry of Health (2016) intends that Sectoral Health Strategy 2017-2021 "be a political and professional guide to the development of the health sector that aims to improve the health status of the population and the satisfaction of patients with health services in the Republic of Macedonia Kosovo "(pg. 9). The Ministry of Health has established the health system reform, one of its priorities is the reorganization of the health sector by increasing the managerial autonomy of health institutions (Ministry of Health, 2016).

Strategic Objective for 2017-2021, the Ministry of Health has the reorganization of the health sector by strengthening the targeting of the Hospital Service and Clinical University of Kosovo; strengthening the managerial structure of HUCSK, enhancing the capacities of the Health Inspectorate, building professional capacities based on identified needs as well as contractor services defined by each organizational unit of HUCSK (Sectoral Health Strategy 2017-2021, 2016).

I.Vl Theoretical Framework in Healthcare Leadership

The health system in Kosovo, despite the numerous attempts through Strategies to improve the managerial quality, still results in very poor performance. This is being influenced by many different factors, ranging from frequent changes to organizational health pillars, political influences, and inadequate managerial education. As health care is growing more and more, then the need for management increases. Leaders of healthcare institutions even though they have academic education, they should also develop the professional development part of the management in order to meet all the requirements for quality achievement, which is essential in health (West, Armit, Loewenthel, Eckert, West & Lee, 2015).

Through HSCUK statute, the scope is determined, organization and functioning of the components of Hospital Service units and University Clinical Kosovo (HUCSK), ways of conducting its activities, as well as the powers, rights, duties, and responsibilities of the management structures of HUCSK (Ministry of Health, 2013). The criteria to be met by the Heads of Health Institutions, based on the Law on Health, Labor Law and in accordance with the Statute of HUCSK are:

• In addition to the specialized qualification, they must have a professor's academic appeal, or in absence, have the title of a doctor of sciences or high professional qualification, as well as the organizational unit to be full-time employees;

• Have scientific degrees in the field of economics or health management of a master's or doctor's degree;

• Have published a university book in the relevant professional field, or in absence, have published three (3) scientific or professional papers in professional or scientific journals of the international rank in the last five (5) years.

• In the absence of candidates who meet the criteria set out above, the final decision on the selection of the Director shall be received by the Minister of Health from among the three (3) candidates proposed by the Governing Board of HUCSK;

• The General Director is appointed by the Board of Directors for a term of three (3) years with a possibility of re-election in the case of outstanding performance (Statute of HUCSK, 2013).

In the Sectoral Health Strategy 2012-2016, it is presented as a conclusion that management skills and knowledge are very scarce for persons in management positions (Ministry of Health, 2012). Leadership and leadership development are vital for health care. According to West (2015), there are no special methods to develop successful leaders because leadership is a sensible process, but development needs to be achieved by formal or informal analysis of the current capacities of the leaders they own or that they should achieve. Leadership and management are complex concepts that are relevant to many different parts of the health system, including private and public sectors (WHO, 2007). As management is one of the pillars of the existence of the health system and has the main purpose of achieving quality performance, it should also take on the knowledge and managerial skills of each person possessing these positions. Leadership competencies can be seen as a result of the leadership's experience, wisdom, and ability to effectively carry out the leadership duties that are presented to them in an organizational context and which have cognitive, behavioral, and emotional components (West, 2015).

Management and leadership are very important to provide good health services (WHO, 2007). Though both are similar in some respects, they can differ in terms of perspective, skills and behaviors. Good managers should strive to be good leaders and good leaders, need leadership skills to be effective. Leaders will have a vision of what can be achieved and then communicate this to others and develop vision vision strategies (WHO, 2007). Leadership and management are the key to achieving the most effective quality of service to a low-risk healthcare system. Good managers ensure effective organization and use of resources to achieve results and meet health goals (WHO, 2007).

Model of Competency of Heads of Health Institutions Under the International Federation of Hospitals (2015)

Source: International Hospital Federation (2015)

The Model of Competency of Heads of Health Institutions under the International Federation of Hospitals (2015) consists of five pillars which are:

• Leadership competences, including: (Skills and leadership behavior, culture and organizational climate, leadership change and innovation support);

• Communication skills and interpersonal relationships where: (Management of staff reports, communication skills, support and negotiation);

• Professional and social responsibility, including: (Personal and professional accountability, continuous professional development, self-reflection and support of ethical values);

• Knowledge of the health and healthcare system environment for: (Knowledge of health systems and organizations, knowledge of health professionals, access to patient-oriented health care, recognition of the public health system);

• Competence of business.

WHO suggests that for achieving health through leadership and management in low income countries, such a low-income example is the Republic of Kosovo should work towards the creation of these objectives; Establish a framework for strengthening leadership and health management in enhancing the quality of health services:

• agreement on management issues in enhancing the quality of health services;

• a set of good practice principles for strengthening leadership and health management in low income countries;

• recommendations on actions (for WHO and others) to further strengthen health care (WHO, 2007).

WHO has drafted a framework for creating the necessary conditions for good management and management. This framework encompasses four dimensions that are interrelated, one of which does not work, and others are affected. The Framework makes clear that management and management activities are a means of achieving effective management of the healthcare system and services, and the integral strengthening of the health system, which includes the provision of adequate number of managers and their placement across the health system, how many managers are employed? How many of their "managers" have the title in their work? How do you combine the managerial role with that of clinical work? Which health levels are managers? Providing managers with the right competencies such as knowledge, skills, attitudes and behaviors that include: Is there a practical competence framework for knowledge, skills, attitudes, and behaviors? What is needed for managerial positions? How do competencies grow? Is there any system for increasing competencies? What qualifications and experiences do managers have? Existence of functional critical support systems (to manage money, staff, information, supplies, and self-management performance (WHO, 2007). The use of different Frameworks in order to improve and improve the leadership's performance is not all the achievement of success, because the problem does not stand in the framework but also in the non-managerial preparation of the leaders (West, 2015). The Ministry of Health (2016), based on the Performance Analysis of Health Institutions, concludes that the health sector needs reassessment and reorganization of the health care network for the purpose of their rational use. Leaders and decision-makers in cooperation with the Ministry of Health should set priorities that address the most important health needs and precede the management of the national health strategy and plan (Terwindt, Rajan & Soucat, 2016). Leadership success plays a major role in co-operation within the institution as well as with other actors outside the institution, achieving the building of an integrative leadership culture, where results the more successful collective leadership than the individual (West, 2015). Therefore, leaders need to work together and build cultures where the success of patient care in general is the priority of every leader, not just the success of their individual areas of responsibility (West, 2015). For a health system to be successful before prioritizing, the current health situation should be analyzed not only through quantitative data but with a qualitative assessment of factors affecting the performance of the health system (Terwindt et al, 2016). In leadership the experience is really valuable to enable leaders to develop their skills in particular when they have the right guidance and support (West, 2015).

Leadership development benefits can go beyond individual level and apply to organizations and patients if participants can transfer their workplace development and improve quality and efficiency in health care (West, 2015). The strategy's success depends on how it is adapted by health care providers, failure to conduct proper behavior can lead to failure of the health strategy. Therefore, leadership plays a key role in the functioning of the strategy, which if implemented as planned, will reflect on the positive performance of patients and all of this is achieved by changing their behavior in order to adapt to the goal of the strategy (Caldwell, Chatman, O'Reilly, Ormiston & Lapiz, 2008). Leadership development leads to increased quality, developed education, and concentration of organizational attention on strategic priorities, but it remains true that leadership experience is a much more valuable factor in enabling leaders to develop their skills especially when they have proper guidance and support (West, 2015). Leadership can have a positive impact on the implementation of the health strategy by cooperating with their clink team and by adapting their behavior based on the requirements of the strategy, but they can also adversely affect by not adopting a management approach to the health strategy (Caldwell et al., 2008). Leadership performance depends on link building and their impact on health institutions and professionals, trying to achieve the highest goals that increase healthcare performance (Goodwin, 2000). The success of the strategy is achieved by co-operating the Ministry of Health together with the leaders of health institutions in order to adapt adequate behaviors that lead to increased performance in patients (Caldell et al, 2008). Effective leaders always emphasize as a top priority safe, high quality and tooth care, making the voice of patients heard at each health level about their experiences, needs as well as the positive or negative reactions that are part of the work (West, 2015). Leadership is the most influential factor in shaping an organizational culture that provides the core leadership, strategy and quality development that is most essential (West, Armit, Loewenthel, Eckert, West & Lee, 2015). Engagement should be manifested by all institutions by taking responsibility and making it a personal priority that helps secure the success of the institution as a whole instead of individual focus or isolated leadership (West, 2015). Facts-based leadership is possible and becomes a reality and is a powerful tool for leading teams to set strategies and goals, and to generate faster results. Leaders have a major impact on the performance of Health Institutions, according to Punka, (2013) if the hospital performance is high then the leader is managing the right course on the path to performance improvement but if the performance results to be low then the direction leadership is wrong. When we have an overview of leadership profiles we can more easily reflect on the current state of health care. Leadership is a powerful tool for leading teams to set strategies and goals, as well as to generate faster results (Punke, 2013). We can appreciate leadership and this is important because we thus advance leadership gaps. Since the managerial and managerial part is of poor quality in Kosovo, as there is a lack of a legal framework for leading positions, this research is needed to reflect on who is managing today in Health Institutions in the Republic of Kosovo and what competences have the current leaders?

The purpose of this research is to examine leadership profiles in the institutions of three public health levels in Kosovo.The main research question: Who is leading the health institutions today in Kosovo?

Follow up Questions:

1. What is the professional development of the leaders of institutions and health services in Kosovo?
2. Is education distinct in the management of medical services to nurses?
3. What is the managerial experience of the current leaders?
4. What is the age of managing institutions and health services?
5. What is the current governing gender of institutions and health services?

II. Methodology

The method of this research is a quantitative approach, with explorative-descriptive design, which examines profiles of current managers and managers in primary, secondary and tertiary public health institutions in Kosovo.

II.I Participants

The sample of this study consisted of 253 participants, who were 48 leading educational institutions and 205 services a leader. According sex 101 participants were women and 151 men. Part of the study were 49 public institutions, 11 of which have been centers of Family Medicine, Mental Health Center 4, 7 and 27 Hospitals Clinic HUCSK 's total of 15 of the Republic of Kosovo. Leaders of institutions of MFMC were (3.95%) participants from HUCSK (11:07%) participants, from being included hospitals (2:23%) participants and the MSC have been (1:58%) participants. Leaders of the services from the Main Family Medicine Centers were (10.28%), from Hospitals participated (70.75%), from the Kosovo Clinical Hospital Clinical Service and the Mental Health Centers we did not have any research participants.

Table 1. Demographic data of participants in Health Institutions

II.II Procedure

Data collection for this research has been done in public health institutions of primary level (MFMC), secondary (hospital) and tertiary (HUCSK). Prior to the implementation of the data collection process, applications were made in each institution that was a target for research, presenting the purpose of the research, as well as explaining which data would be relevant to the research. After the approval of the requests, the process of data collection has begun, where all ethical rules have been respected regarding the data we have requested. For collecting the data that were collected for research we have found legal support to LAW NO. 03 / L-215 on access to legal documents.

This law guarantees the right of every natural and legal person, without discrimination on any ground, to have access, upon request, to documents held, drafted or received by public institutions. Research data are secondary data, as they are readily available from each health institution that was the target of the research. The focus of the research was only the managerial positions of the three levels of Health Institutions (senior, middle and low management). The data we collected for research includes: gender, type of institution, institution health level, managerial experience, clinical experience, education, age and type of management. Data on HUCSK have been obtained from the Health Information System (HIS), while some Hospitals and Main Family Medicine Centers (MFMCs) have been taken from those institutions. The data collection period began on June 15 and lasts until August 30, 2017, while data analysis is done through the SPSS (Social Science Statistics) version 21 and Excel. The data collected will be used only for research and will be treated with caution.

III. Results

The results of this research convey the answer to the main research question: Who is leading health institutions today in Kosovo? Institutions and health services are run by professional health professionals, namely in the clinical field based on the research results, of which the institutions are 8.16% with general practitioners, with 4.08% surgery, with (3.40%) doctors of family medicine. Whereas, health services (4.06%) are specialist doctors (3.40%) are specialist in gynecology, pulmonology and dermatology specialists, and (2.72%) are specialist in cardiology and ophthalmologists.

Figure 1. Professional Development of Leadres of Institutions and Services

Research question: What is the professional development of the leaders of health institutions in Kosovo? According to the type of health institutions, the professional development of the managers of institutions and services in MCMF has a higher percentage of specialized education with (5.65%), in hospitals is preceded by education with specialization with (29.44%), in HUCSK we have education with specialization with (8.47%) as well as in mental health education centers integrated studies with (1.61%).

Figure 2. Professional Development of Leaders of Institutions and Services by the Type of Institutions that Lead

According to the education of the health levels in the health institutions we have the secondary level which dominates the four educational levels with a higher percentage than the primary and tertiary level.

Figure 3. Education and Health levels

The professional development of the leaders of the institutions and services is exaggerated by the following results: leaders of institutions with secondary education do not have, with BSc we have (0.40%), with integrated studies (8.47%) and with specialization (10.48%). Heads of secondary education are (26.21%), with BSc (14.92%), with integrated studies (6.45%) and with specialization (33.06%).

Figure 4. Professional Development of Leaders and Institutions and Services

To the research question: does education differ in the management of medical services to nurses? The results of the research reflect the difference of professional development in the management of medical services to nurses, of which 40.70% medical specialists are with specialization, with integrated studies (8.04%) and BSc (1.01%), (32.66%), with BSc (17.59%), with integrated studies and specialization we do not have in nursing management.

Figure 5. Physician Education and Nursing Management

Heads of Institutions and Health Services in secondary education dominate age 46-55 (9.86%), BSc education dominates age 26-45 (7.79%), integrated studies are aged 46-55 and over 56 years as well as specializations are over 56 years old (23.36%).

Figure 6. Professional development according to age

The professional development of Heads of Institutions and Services by gender is reflected in the following results: in secondary education we have feminine gender with (18.15%), BSc dominates with (11.29%) females, in integrated studies we have male gender with (12.50%) and in the specializations we have male gender with (35.89%).

Figura 7. Ngritja profesionale në bazë të gjinisë tek Udhëheqësit e Institucioneve dhe Shërbimeve

Refering the research question: What is the managerial experience of the current leaders? The survey reflects the fact that the managerial experience of the current leaders of healthcare institutions and healthcare services with 1-5 years, 6-10 years and 11-20 years dominates the secondary level.

Figure 8. Management Experience of Leaders by Health Sector

Based on the results obtained from the research, the professional growth of managers with 1-5 years of high school and BSc managerial experience is (8.52%), with integrated studies (1.14%) and specialization (19.89%). Management experience 6- 10 years for highschoolleaders is (7.39%), with BSc (5.11%), with integrated studies (1.70%) and specialization (16.48%). As for managerial experience11-20 years, leaders with secondary education are (14.77%) with BSc (3.41%), with integrated studies (1.14%) and specialization (11.93%).

Figure 9. Managerial experience of leaders by education

Managerial experience 1-5 years of female leaders was (17.32%), while male leaders (21.23%), managerial experience 6-10 years were (10.61%) leading women and (20.11%) male leaders while with 11-20 years of managerial experience were (16.20%) leading women and

(14.53%) male leaders

Figure 10. Management experience by gender

In research questioning what age is leading health institutions? The research shows that the age that leads institutions and health services on the basis of research results reflects the age of 26-45 years with (1.20%) leading institutions while with (18.47%) service leaders, aged 46-55 years (8.43%), while with (30.52%) service leaders, while over the age of 56, we have (9.24%) leading institutions and (32.13%) service leaders.

Figure 11. Age of Institution Managers and Service Managers

The service leaders, divided into leaders of medical services and nursing care services by age, have the following results: with age of 26 to 45 years (4.48%) are medical leaders while with (18.41%) years are nurses leading 46- 55 years are with (18.91%) medical leaders and with (18.41%) are nurses, while over 56 years are (25.87%) medical leaders, and with (13.93%) are nurses.

Figure 12. Age of physician managers and nursing managers

Research results of the research question: What is the gender that is leading the institutions and health services? The result is that women (3.57%) are leaders of institutions and (36.51) are leaders of services, while men with (15.48%) are leaders of institutions and (44.44%) are leaders of services.

Figure 13. Gender by type of leadership

Iv. Discussion

Who is leading the health institutions today in Kosovo has been the general research question. And this research based on facts justify the research supports that health institutions are governed by educational profiles in clinical areas and not in those management.

Research Question 1. What Is the Professional Development of the Leaders of Health Institutions in Kosovo?

Health care institutions are managed and managed by the clinician profile, not by the adequate profile of the managerial management section. Professional growth of professionals results only in clinical areas, institutional leaders dominate with vocational advancement, while those with integrated and secondary education services. This shows that, besides the current leaders, they do not have the proper professional growth in the managerial fields, they are also with a low level of professional development in clinical fields. This reflection of the professional upgrading of institution and service leaders shows an indication why the performance in healthcare institutions is not so enjoyable as leaders with adequate managerial competencies are key to the success of Institutions and Health Services. However, one thing that is borne out by this research is the criterion for institutional leaders, which includes the statute of HUCSK, which are more criteria for the clinical part than for the managerial, and that are not in line with the models of different European. If we compare it to the model of the International Hospital of Hospitals (2015), which represents the basic competencies for a leader, none of them is included in the statute of KPSHK, which used as a basis for selecting the leaders of health institutions. According to West (2015), each leader should have in-depth knowledge and managerial skills.

Research Question 2: Is Education Distinct in the Management of Medical Services to Nurses?

Based on the results of the research this research question has two answers, firstly, the distinctiveness of education is not observed in their education profile because they all belong to the clinical field but their level of education presents the distinction between medical management in the field their clinical studies have integrated studies and specialization, unlike nursing management, most of them with secondary education. This raises the concern that health institutions are being run by persons who are not in the relevant field but also that the clinical part is not even professionally established. This situation has an impact on the Health System in Kosovo, because there is no model on which the share of leadership of institutions and health services is based, which if existed there would be a foundation whereby the most obvious leadership path would be and with safe steps towards improving healthcare performance.

Research Question 3: What Is the Managerial Experience of Current Leaders?

As far as managerial experience is concerned, we only reflect results for primary and secondary level as the reason for lack of data from the tertiary level, at both levels as primary level as secondary level, is a managerial experience roughly 1-5 years of managerial experience, with 6-10 years, as well as 11-20 years of managerial experience. This shows a wide variety of managerial experiences of leaders, of which we have a leader who is in the first mandate second, but we have leaders who have more than 6 mandates to lead institutions and services. If based on research, leadership competencies can be seen as a result of the leader's experience (West, 2015), which is not so present in us.

Research Question 4: What Age Is Leading Institutions and Health Services?

The age that dominates the heads of institutions and health services is between the ages of 46-55 and with a similarity with leaders over the age of 56. Likewise, this is also related to managerial experience, rather than the fact that leaders are older they also have the greatest managerial experience.

Research Question 5: What Is the Gender Governing the Institutions and Health Services?

Health institutions and services are mostly driven by men rather than women, men dominate both institutional leadership and service leadership, this may be related to the reason that education is lower among women than men, although in management areas do not have both sides professional upgrades and both sides are equal. The results of this research tell us the situation of the leaders of Institutions and Services, which are affecting the current state of health development. Organization of institutions and services by people who are very affluent in the clinical part and have professional upgrading of the clinical field, leading institutions and health services without having any competence in the field of management and management in health. This shows that Health is run by persons who are not relevant to leadership and management.

V. Conclusion

Leadership is the most influential factor in shaping organizational culture, providing leaders' essential behaviors, strategies, and quality development that is essential to health. Training and management skills are key to the leader's success in the right direction. From this research, we have provided a foundation for profiles of leading institutions and public health services in Kosovo. The research points out that the current leaders of health care institutions and services are educated in the clinical, not managerial, field of education that needs to be adequate. They do not have the basic foundation that fits in with managerial competencies for the managers of institutions and management services. Also, the education of doctor’s managers is higher in contrast to nursing management. As for managerial experience at primary and secondary level, there is little difference between years, where we have different managers, from 1 to 6 mandates. The age that is leading healthcare institutions is 46-55 years as well as over 56 years. As far as gender is concerned, masculine dominance is also in the leadership of services and in the leadership of the institutions. From this research we can say that Health Institutions and Services are guided by health profiles with professional advancement in clinical areas rather than those of adequate managerial profile. This shows an indicator that may influence the not so good quality that is prevalent in current health in the Republic of Kosovo.

But for the performance enhancement in the leadership aspect is accompanied by a set of recommendations ...

VI. Recommendation

Based on the literature review and actual results, the health system in the Republic of Kosovo should have a Framework for Management and Management of Institutions and Health Services, it should review and adapt the criteria of HUCSK to Heads of Health Institutions, Current Leaders with academic degrees in managerial profile in Healthcare, have trainings and managerial advancements for the actual leaders, assess the performance of leaders from their work team, make division of clinical work from managerial to leadership, obtain managerial models from countries that have good quality healthcare performance and the adaptation of the WHO Framework, which is a framework that contains the basic criteria for leadership, a framework that is made for countries with low financial incomes and states that jan transition such as Kosovo.

Continuity of research- Continuing research in knowing practices and management experience, investigating managerial behavior and their impact on the quality of services, as well as sharing managerial and clinical aspects.

Limits of Research

As with any other research we have encountered some limitations during the research process, which was the non-cooperation of some health instructors for the conduct of the research, the short time for data collection in all Public Health Institutions of the Republic of Kosovo, the scope of the research in both other public and private institutions, lack of data on service management for HUCSK, and lack of data on managerial experience and clinical experience for HUCSK.

References